Scoping Review: Home and Community-Based Service Waiver Programs and Person-Reported Outcomes

Abstract State Medicaid programs are rebalancing their long-term care spending from nursing home to home and community-based services (HCBS). Emphasis on person-centered and person-directed care warrants investigation into models of HCBS delivery that promote quality of life. We performed a scoping review of the literature to catalogue the breadth of the studies describing HCBS waiver programs targeting adults (18+). We identified 757 articles, and after duplicate removal and reconciliation, we excluded articles on children or adolescents, non-peer reviewed reports, international studies, and articles that did not describe HCBS waiver programs. After abstract and title review, 292 articles met our inclusion criteria. Most included articles (22.3%) were single state descriptive evaluations or evaluations of service use patterns among participants. 17.8% of included articles examined multi-state or national variation in program trends, while 17.1% made national program conclusions without a major focus on interstate comparison. Less common were studies examining integrated care or dual-eligibles (7.5%), PACE (3.4%), medication management (3.1%), quality and satisfaction of both consumer and caretaker perspectives (3.8%) and consumer-only perspectives (5.1%). The remaining articles focused on HIV (4.1%), TBI (1.4%) or ID/DD (14.4%) waiver programs. The 8.9% of articles addressing quality and satisfaction consisted mostly of interviews, either with state Medicaid administrators or with care recipients and/or caregivers. Consumer reported satisfaction and unmet care needs were the primary outcomes examined. Given the heightened focus on long-term care as a result of the ongoing coronavirus pandemic, this review justifies further exploration into the delivery and outcomes of state-directed HCBS waiver programs.


MEANINGFUL ASSESSMENT OR MINIMUM COMPLIANCE: PASRR FOR NURSING HOME RESIDENTS WITH MENTAL ILLNESS
Taylor Bucy, 1 Kelly Moeller, 1 John Bowblis, 2 and Tetyana Shippee, 1 , 1. University of Minnesota,University of Minnesota,Minnesota,United States,2. Miami University,Oxford,Ohio,United States The Omnibus Budget Reconciliation Act (OBRA) of 1987 included provisions for the Preadmission Screening and Resident Review (PASRR) program, which requires states to create and maintain systems to assess persons with serious mental illness (SMI) seeking NH care. The prevalence of SMI in NHs is increasing, and little is known about the effectiveness of the PASRR program intervention. We conducted 20 interviews with state and national PASRR stakeholders, including assessors, hospital discharge planners, mental health advocates, geriatricians and geriatric psychiatrists. Interview data were triangulated with state provided materials on PASRR collection and implementation. Based on these interviews, we identified four themes: 1) variation in the implementation of federal PASRR legislation across states and jurisdictions, 2) the need for investment in professional development and workforce capacity, 3) lack of usefulness of PASRR in ongoing care planning, and 4) the need to consider the role of age, race/ethnicity, and stigma on quality of care for NH residents with SMI. Stakeholders agree that PASRR legislation was well intentioned, but also expressed concern regarding the completion of PASRR as an issue of compliance versus meaningful assessment. More work is needed to determine how best to develop and support the care needs of people with SMI, while being mindful of the original goals of deinstitutionalization that prompted OBRA passage. In order to assess the impact of the PASRR program on quality of care and mental health outcomes, further research should take an evaluative approach through meaningful use of PASRR data. The number of older adults who live in long-term care (LTC) is expected to increase worldwide. The COVID-19 pandemic has caused serious consequences in Canadian LTC homes, while homes in China and Japan reported minimal infection and death rates in residents. The differences in LTC policies may be one of the contributors. The purpose of this literature review was to identify elements of the LTC policies that might have impacted COVID-19 outcomes in LTC homes in Canada, China, and Japan. A scoping review was conducted following the framework proposed by Arksey and O'Malley. Scholarly articles and grey literature published between January 2015 and June 2020 were identified in six databases, four in English (CINAHL, Scopus, ProQuest, and PubMed), one in Chinese (CNKI), and one in Japanese (CiNii), using MeSH terms for LTC and health policy. Grey literature was identified using Google. Data were extracted, summarized and common themes identified through content analysis. A total of 52 articles and 26 grey sources were included in the review based on determined inclusion criteria. They were research articles, reviews, government or association reports, policy briefs, policy documents, and guides. Four common themes of challenges emerged: caregiver workforce, service provision, funding, and physical environments. Three sub-themes were identified for caregiver workforce and service provision. Differences in COVID-19 consequences in LTC homes in the three countries seem to be related mainly to the challenges with the caregiver workforce and the lack of funding. The result suggests Improvements of LTC policies are required, especially in Canada. State Medicaid programs are rebalancing their long-term care spending from nursing home to home and communitybased services (HCBS). Emphasis on person-centered and person-directed care warrants investigation into models of HCBS delivery that promote quality of life. We performed a scoping review of the literature to catalogue the breadth of the studies describing HCBS waiver programs targeting adults (18+). We identified 757 articles, and after duplicate removal and reconciliation, we excluded articles on children or adolescents, non-peer reviewed reports, international studies, and articles that did not describe HCBS waiver programs. After abstract and title review, 292 articles met our inclusion criteria. Most included articles (22.3%) were single state descriptive evaluations or evaluations of service use patterns among participants. 17.8% of included articles examined multi-state or national variation in program trends, while 17.1% made national program conclusions without a major focus on interstate comparison. Less common were studies examining integrated care or dual-eligibles (7.5%), PACE (3.4%), medication management (3.1%), quality and satisfaction of both consumer and caretaker perspectives (3.8%) and consumer-only perspectives (5.1%). The remaining articles focused on HIV (4.1%), TBI (1.4%) or ID/DD (14.4%) waiver programs. The 8.9% of articles addressing quality and satisfaction consisted mostly of interviews, either with state Medicaid administrators or with care recipients and/ or caregivers. Consumer reported satisfaction and unmet care needs were the primary outcomes examined. Given the heightened focus on long-term care as a result of the ongoing coronavirus pandemic, this review justifies further exploration into the delivery and outcomes of state-directed HCBS waiver programs.

THE DEVELOPMENT OF A SELF-APPRAISAL TOOL FOR THE LEVEL OF LONG-TERM CARE SERVICE INTEGRATION.
Yu-Chien Chang, 1 and Ya-Mei Chen, 2 , 1. National Taiwan University, Taiwan, Taipei, Taiwan (Republic of China), 2. National Taiwan University, Taipei, Taipei, Taiwan (Republic of China) Introduction Taiwan is the fastest aging countries in the world. In 2016, Taiwan implemented Long-Term Care Plan 2.0 (LTC Plan 2.0), aims to provide coordinated and integrated LTC services. However, how to assess the level of integration and which integration mechanisms are better applied are still unclear in the literature. This study intended to address a research question regarding "How can agencies measure their level of service integration?" and, therefore, aimed to develop an integration assessment tool-the Taiwanese Self-Assessment for LTC Systems Integration (TwSASI)-for LTC agencies to use to self-evaluate their current "level" of providing integrating LTC services. Methods TwSASI was first developed base on Connie J. Evashwick's (2005) framework and literature review, including four domains: inter-entity planning and management, care coordination, integrated information system, and integrated financing, and 11 dimensions with 51 items. Through the Delphi method, with two rounds of investigation and feedback from 26 experts, RAND/UCLA Appropriateness Method (RAM) was used to assess the consensus regarding the dimensions and items developed and refined the tool content accordingly. Results After two rounds of investigation, four domains remained with 10, 11, 4, and 5 items in each domain respectively. All items reached good experts' consensus with medians of the 30 items' importance, feasibility, and appropriateness all over 8. The Scale Content Validity Index (SCVI) of the 4 dimensions all over than 0.9. Conclusion The TwSASI can be feasible for evaluating the level of LTC service integration in Taiwan. LTC agencies can improve their level of service integration accordingly.

WHO IS COMING TO JAPAN UNDER THE NEW STATUS OF RESIDENCE "SPECIFIED SKILLED CARE WORKERS"?
Noriko Tsukada, Nihon University, Tokyo, Tokyo, Japan The Japanese government created a new status of residence called "Specified Skilled Workers" encompassing 14 job categories that have laborer shortages, including long-term care (LTC) workers on April 1, 2019. A survey of students (N=79) at a language institute in Manila, Philippines was conducted in February, 2020 to explore characteristics of future foreign LTC workers in Japan under this new status of residence and identify factors that may help facilitate worker retention. At the time of data collected, these students were studying both Japanese and LTC practices in order to pass skill evaluation tests to enter Japan. Students were asked their perceptions of long-term care, planned lengths of stay, concerns about staying in Japan, and future career plans. Preliminary analyses revealed that 67 (88%) were single, 74(93.7%) had graduated from universities, and a half of them had a nursing background. Most students (93.7%) showed interest in an extended stay in Japan, with some interested in taking the national certified care worker examination which permits extended work in Japan. The most cited concern about being in Japan was "weather, climate and typhoons" (28.1%), followed by "language proficiency" and "living expenses" (21.9%) respectively. As Japan has limited immigration policies but a large need for LTC workers, it is imperative to understand how to attract and retain foreigners who obtain the Specified Skilled Worker status. This includes addressing both work-related and living-related concerns and needs.

DIRECT CARE WORKERS EMPLOYED AS MEDICAL AIDES: HOME HEALTH AIDES, NURSING ASSISTANTS, AND ORDERLIES
Christopher Kelly, and Jerome Deichert, University of Nebraska at Omaha, Omaha, Nebraska, United States Purpose: This study describes the differences among direct workers (DCWs) employed as medical aides in three occupations: home health aides, nursing assistants, and orderlies. Design and Methods: Data were from the 1% Public Use Microdata Sample (PUMS) of the 2019 American Community Survey (ACS). Logistic regression was used to compare demographic and employment characteristics of DCWs employed as medical aides in three occupations: home health aides, nursing assistants and orderlies.
Results: Compared to orderlies and psychiatric aides, home health aides are more likely to be foreign born, more likely to be female, less likely to work in institutional settings, less likely to be under age 25, less likely to work year-round